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Arterial grafting for coronary revascularisation and the illusive search for truth
  1. Paul A Kurlansky
  1. Correspondence to Dr Paul A Kurlansky, Department of Surgery, Columbia University, 210 Black Building, 650 West 168th Street, New York, NY 10032, USA; doctorwu18{at}aol.com

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The art of medicine might well be described as the ability to make the right decisions based on incomplete information. Try as we might to provide ‘evidence–based’ care, the more scientifically candid among us will confess that the ‘definitive study’ on any given topic never has been (nor ever will be) performed. Indeed, a careful 2009 review of the vaunted American College of Cardiology (ACC)/American Heart Association (AHA) guidelines available at that time demonstrated that, in total, less than 10% of recommendations were based on level of evidence (LOE) A (randomised controlled trials (RCTs) or meta-analyses of RCTs), whereas more than half relied on LOE C (studies without controls or expert opinion).1

Despite remarkable and ongoing advances in percutaneous interventions, both meta-analyses of RCTs2 and longitudinal analyses of large registry data3 continue to document the comparative long-term survival benefit of surgical revascularisation for patients with extensive coronary artery disease. Given the now-classic demonstration of the improved survival with the use of the left internal thoracic (or mammary) artery (LITA) rather than saphenous vein grafts (SVGs) for bypassing a diseased left anterior descending coronary artery (LAD), the subsequent demonstration of improved patency of ITA versus SVGs and the clear correlation with improved survival4 would seem to make the rationale for the use of two rather than one ITA somewhat compelling. In fact, meta-analyses addressing this very issue have demonstrated a superior long-term survival benefit for bilateral versus single ITA grafting in patients with extensive coronary artery disease. To these reviews, the meta-analysis presented by Buttar et al herein adds information regarding favourable perioperative and long-term clinical parameters that also appear …

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